Provider Demographics
NPI:1124220512
Name:PRIDGEN CHIROPRACTIC & WELLNESS CENTER PC
Entity Type:Organization
Organization Name:PRIDGEN CHIROPRACTIC & WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PRIDGEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:229-244-5314
Mailing Address - Street 1:3338 COUNTRY CLUB RD
Mailing Address - Street 2:BLDG F STE3
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-1044
Mailing Address - Country:US
Mailing Address - Phone:229-244-5314
Mailing Address - Fax:
Practice Address - Street 1:3338 COUNTRY CLUB RD
Practice Address - Street 2:BULDG F STE3
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1044
Practice Address - Country:US
Practice Address - Phone:229-244-5314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1133111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6617Medicare ID - Type UnspecifiedGROUP